REPUBLIC OF THE PHILIPPINES)

Province of Cagayan
) SS.
AFFIDAVIT OF LOSS
I, ______________, of legal age, _______, and with postal address at
______________________, after having been duly sworn to in accordance
with law, do hereby deposes and says:
1. _________;
2. _________;
3. _________;
4. _________;
5. _________;
6. That I am executing this affidavit to attest the truth of the
foregoing allegations and for whatever legal purpose this
may serve.
AFFIANT FURTHER SAYETH NAUGHT.
IN WITNESS WHEREOF, I hereby affixed my signature this ___th
day of January 2006 at the City of Manila.

______________
Affiant
SUBSCRIBED AND SWORN to before me this ___th day of ______,
____ at the City of ________.
Notary Public
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of _____.